Labour

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This ppt explains about labour, its stages, physiological changes & its management. It also explains about nursing process of women in labour. It explains about mechanism of labour

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Labour

  1. 1. LABOUR
  2. 2. LABOURMrs. P. Vadivukkarasi Ramanadin,Asst. Professor,Mata Sahib Kaur College of Nursing,Mohali, Punjab.
  3. 3. INTRODUCTION3 Normal labour and delivery is a physiologic process in which the attendant closely monitor the woman and fetus, with little medical Intervention required. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  4. 4. DEFINITION4 It is the process of expulsion of fetus, placenta and its membranes through the birth canal. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  5. 5. NORMAL LABOUR / EUTOCIA5 Normal labor occurs  at term,  spontaneous in onset,  fetus presenting by the vertex,  it complete within 18 hours,  no complication arise. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  6. 6. STAGES OF LABOUR6  First stage (or) Dilating stage  Second stage (or) Pushing stage (or) pelvic stage  Third stage (or) Placental stage  Fourth stage (or) Recovery stage Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  7. 7. FIRST STAGE OR DILATING STAGE7 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  8. 8. DEFINITION8 It starts with regular and rhythmic uterine contractions till completion of full cervical dilatation (10cm). DURATION :  For primi gravida 16hrs to 18hrs.  For multi gravida 6hsrs to 10hrs. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  9. 9. ONSET OF LABOUR9 1.Prelabour 2.Lightening 3. Frequency of micturition 4.Taking up of cervix and Cervical Effacement Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  10. 10. Difference between True labor and False labor Niggling / Spurious labor / False labor True labor Uterine contraction : Uterine contraction : Not always present Always present Lasts for 3 to 4 minutes Not exceed > 90 seconds Irregular Regular and rhythmic Felt in lower back radiates to lower Felt in back or abdomen above navel Portion of abdomen May or may not be painful Abdominal tightening ,discomfort and Can stop with comfort measures Pain will not stop with comfort measures No back ache May have back ache Intensity stop with position changes, Increase intensity with walking Walking Cervix : Cervix : No shortness , Soft Shortening No dilatation Dilatation No tensed membrane Tensed membrane Posterior position Anterior position No show Show presents Fetus : Fetus : No head engagement Head engagement10 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  11. 11. CAUSES OF ONSET OF LABOR11 Exact cause is unknown .i ) Hormonal factors : Formation of Oxytocin receptors in uterine muscles by the influence of Estrogen . Which act with Prostaglandin secreted from Decidua and membrane triggers the uterine contraction. Emotional and physical stress stimulates Hypothalamus to release Oxytocin which triggers the uterine contraction .ii ) Mechanical factors : Pressure exerted by presenting part to the os of cervix initiates uterine contraction Mohali, Punjab 8/25/2012 Mata Sahib Kaur College of Nursing,
  12. 12. PHASES OF FIRST STAGE OF LABOR12 Have 3 phases * Latent phases * Active phases * Transition phases Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  13. 13. MATERNAL PROGRESS IN I STAGE OF LABORCriteria Latent phase Active phase Transition phaseDuration Primi gravida 8 – 10 hrs 3 – 6 hrs 2 hrs Multi gravida 5 hrs 4 hrs 1 hrContraction Strength Mild – Moderate Moderate – Strong Strong – Very strong Rhythm Irregular More regular Regular Frequency 5 – 30 mts 3 – 5 mts 2 – 3 mts Duration 30 – 45 seconds 40 – 70 seconds 45 - 90 secondsCervical dilatation 0 – 3 cm 4 – 7 cm 8 – 10 cm 1.2 cm / hr in Primi 1 cm / hr in Primi 1.5 cm / hr in Multi 2 cm / hr in MultiStation of the head Primi gravida 0 +2 cm +3 and above Multi gravida -2 to 0 cm +1 to +2 cmShow Brownish Pale pink Pink to bloody Bloody mucus discharge mucus13 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  14. 14. PHYSILOGY OF I STAGE OF LABOUR14 I . UTERINE ACTION II . MECHANICAL FACTORS Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  15. 15. I.UTERING ACTION15 1.Fundal dominance 2.Polarity 3.Contraction and retraction 4. Formation of upper and lower uterine segment 5.Retraction Ring 6.Cervical effacement 7. Cervical dilatation 8. Show Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  16. 16. II. MECHANICAL FACTORS16 1. Formation of the fore waters 2. General fluid pressure 3. Rupture of the membrane 4. Fetal Axis pressure Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  17. 17. RECOGNITION OF I STAGE OF LABOR17  Show  Uterine Contraction  Rupture of membrane Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  18. 18. NURSING MANAGEMENT18 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  19. 19. NURSING DIAGNOSES IN THE FIRST STAGE OF LABOUR19 Acute pain / Impaired comfort related to contraction – related hypoxia, dilatation of tissues and pressure on adjacent structures as evidenced by verbal reports, restlessness, muscle tension and narrowed focus Impaired urinary elimination related to altered intake, dehydration as evidenced by urinary retention / slow progression o f labour Fatigue related to discomfort / pain / increased energy requirement / altered coping ability Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  20. 20. Cont . . .20 Risk for mild anxiety related to situational crisis, unmet needs, stress Risk for ineffective coping (individual / couple) related to situational crises / personal vulnerability / use of ineffective coping mechanism / inadequate support system / pain Risk for decreased cardiac output related to decreased venous return / hypovolemia / changes in systemic vascular resistance Deficient knowledge regarding progression of labour and available options related to lack of exposure / recall / information misinterpretation / evidenced by questions / statement of misinterpretation / inadequate follow through of instructions Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  21. 21. NURSING MANAGEMENT IN I STAGE OF LABOR  1) Latent phase :21 •Complete admission procedures •Physical examination •Monitor maternal vital signs •Monitor FHR •Status of amniotic fluid •Status of membrane •Observe voiding •Assess coping ability •Encourage walking •Encourage visiting , watching TV •Encourage relaxation •Change position every ½ hours •Effleurage •Monitor Cervicogram Mata Sahib Kaur College of Nursing, Mohali, Punjab8/25/2012 •Monitor Partogram
  22. 22. 2) Active phase22 •Continue monitor maternal vital signs •Status of amniotic fluid •Encourage voiding every 1 hour •Observe for full bladder •Asses progress of labor •Provide comfort measures •Moist lips or give ice chips •Apply cool , damp cloth to woman’s face •Keep bed linens dry Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012 •Effleurage
  23. 23. Cont . . .23 •Sacral support •Oral hygiene •Inform the progress •Administer medication if necessary •Explain electronic fetal monitor •Encourage breathing and relaxation technique •Frequent perineal care •Protect from aspiration and injury Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  24. 24. 3) Transition phase24 •Continue the active phase management •Do not allow alone •Accept the behaviour of the mother •Change chux ( pad ) frequently •Keep bed linen dry •Get blanket if cold Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  25. 25. SECOND STAGE OF LABOUR / PUSHING STAGE / PELVIC STAGE 25 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  26. 26. DEFINITION26 It begins with full cervical dilatation (10cm) till the birth of the baby. DURATION :   Primi gravida - 2 hours.  Multi gravida - 30 minutes. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  27. 27. RECOGNITION OF COMMENCEMENT27 OF II STAGE OF LABOUR    Expulsive uterine contraction  Rupture of the fore waters  Dilatation and gaping of anus  Appearance of present part  Congestion of the vulva  Show Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  28. 28. PHASES OF SECOND STAGE OF28 LABOUR Have 3 phases * Latent phases / Propulsive phase * Active phases / Expulsive phase *Transition phases / Compulsive phase Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  29. 29. Cont. . .29  LATENT PHASES / PROPULSIVE PHASE : Descend of the fetus 2 cm below from the os to the pelvic floor .  ACTIVE PHASES / EXPULSIVE PHASE : Descend of the fetus from the os 2cm below to the vaginal outlet ( Crowning ) Ferguson reflux : Pressure exerted by the presenting part over the cervix causing involuntary uterine contraction    TRANSITION PHASES / COMPULSIVE PHASE : Birth of the baby from the vaginal outlet till extension . Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  30. 30. PHYSIOLOGY OF II STAGE OF LABOUR30 I Uterine action  Contraction becomes stronger, longer but less frequent.  Membranes rupture spontaneously.  Consequent drainage of liquor allows the hard, round fetal head to be directly applied to the vaginal tissues and aid distension.  Fetal axis pressure increasing the flexion of the head which results in smaller presenting diameter ,more rapid progress and less trauma to both mother and fetus.  Expulsive contraction.  Compulsive contraction  Involuntary uterine contraction. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  31. 31. Cont . . .31II Soft tissue displacement :  As the hard fetal head descend, the soft tissue of the pelvis become displace.  Anteriorly the bladder is pushed upwards into the abdomen which cause stretching and thinning of the urethra.  Posterioly the rectum becomes flattened into the sacral curve and the pressure of the advancing head expels any residual faecal matter.  Laterly the Levator ani Muscles dilate and thins out and perineal body is flattened ,displaced ,stretched and thinned. 8/25/2012 Mata Sahib Kaur College of Nursing, Mohali, Punjab
  32. 32. MECHANISM OF NORMAL LABOUR /32 CARDINAL MOVEMENTS OF LABOURDEFINITION As the fetus descends, soft tissue and bony structures exert pressures which force the fetus to negotiate the birth canal by a series of passive movements collectively known as Mechanism of labor.PRINCIPLES  Descent takes place throughout the labor.  Whichever part leads and first meets resistance of the pelvic floor will rotate forwards until it comes under the symphysis pubis.  Whatever emerges from the pelvis will pivot around the public bone. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  33. 33. CHARECTERISTICS Lie is longitudinal33   Attitude is one of good flexion  Presentation is cephalic presentation  Position is right or left occipito anterior  Denominator is the occiput  Presenting part is the posterior part of the anterior parietal bone  Occiput pointing left / right ileo pectinal eminence  Sagital sutures lies on right / left oblique diameter  Presenting diameter is suboccipito frontal 10cm Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  34. 34. CARDINAL MOVEMENTS34 1) Descend 2) Flexion 3) Internal rotation of the head 4) Extension of the head 5) Restitution 6) Internal rotation of the shoulder 7) External rotation of the head 8)Lateral flexion of the body Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  35. 35. Cont . . .35 1) Descend:  In primi gravida it occurs during latter weeks of pregnancy  It will be aided by  Forces of uterine contraction and retraction  Rupture of fore waters  Full cervical dilatation  Maternal efforts speeds progress  Slope of the pelvic floor muscle 2) Flexion:  This increases throughout the labor  Because of uterine contraction, fetal axis pressure will be exerted more on the occiput than the sinciput causing good flexion  Because of flexion the suboccipito frontal 10cm is reduced into suboccipito bregmatic 9.5cm  The occiput is the leading part Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  36. 36. Cont . . .36 3) Internal rotation of the head:  Because of gutter – shaped and slope of pelvic floor gives resistance  The slope of the pelvic floor determines the direction of rotation  The second principle applied. The occiput is the leading part and meets the pelvic floor resistance and it will rotate 1/8 of the circle forward until it comes under the symphysis pubis.  Because of internal rotation there is a twist at the neck.  The sagital suture move from right or left oblique to Antero – posterior diameter 4) Crowning:  The occiput slips beneath the sub-pubic arch and crowning take place  The presenting part engages the vaginal outlet and it will not recede backward.  The sub-occipito bregmatic diameter 9.5cm distends the vaginal outlet. Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  37. 37. Cont . . .37 5) Extension of the head:  Once crowning occur fetal head can extend  Third principle applied  The fetal head pivot around the the pubic bone  This releases sinciput, face and chin sweeps the perineum and born by a movement of extension.  The suboccipito frontal diameter 10cm distends the vaginal outlet 6) Restitution:  The occiput moves one-eighth of a circle towards the side from it started  Because of this the twist in the neck of the fetus which resulted from internal rotation is now corrected by a slight un twisted movement Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  38. 38. 38 7) Internal rotation of the shoulder:  Now the shoulder is the leading part which meets the pelvic floor resistance  Again second principle applied  So from oblique diameter it will turn to Antero – posterior diameter 8) External rotation of the head:  The head rotate in same direction as restitution and the occiput of the fetal head now lies laterally 9) Lateral flexion:  Anterior shoulder deliver by downwards and backward movement and posterior shoulder deliver by upward and forward movement  Body will be delivered by lateral flexion Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  39. 39. NURSING DIAGNOSES IN THE SECOND STAGE OF LABOUR41 Acute pain related to contraction – related hypoxia, dilatation of tissues and pressure on adjacent structures as evidenced by verbal reports, restlessness, muscle tension and narrowed focus Risk for impaired fetal gas exchange related to mechanical compression of head or cord / maternal position / prolonged labour affecting placental perfusion / effects of maternal anaesthesia / hyperventilation Risk for impaired skin / tissue integrity related to untoward stretching / laceration8/25/2012 Mata Sahib Kaur College of Nursing, Mohali, Punjab
  40. 40. Cont . . .42 Risk for fatigue related to anxiety / environmental humidity Risk for deficient fluid volume related to lack of intake or excessive vascular loss Risk for infection related to broken or traumatized tissue / increased environmental exposure / rupture of amniotic membrane Risk for fetal injury related to descent / pressure changes / compromised circulation / environmental exposure Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  41. 41. NURSING MANAGEMENT OF II STAGE43 OF LABOR  Assess FHR  Assess uterine contraction  Assess the progress of labor  Arrange the delivery room  Follow a sterile technique  Clean vulva and perineal region using downward strokes  Support woman  Provide necessary materials and equipment  Provide equipment for episiotomy  Provide perineal support  Give immediate care  Assess the APGAR score for 1st , 5th , 15th minutes  Assess for haemorrhage Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  42. 42. III STAGE / PLACENTAL STAGE44 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  43. 43. DEFINITION45 It starts with separation of placenta till expulsion of placenta . DURATION :  Primi gravida :15 minutes  Multi gravida : 5 – 15 minutes Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  44. 44. PHYSIOLOGY OF III STAGE OF LABOR46 I) MECHANICAL FACTORS II) HAEMOSTASIS 1) Retractionring / Living ligature 2) Presence of Vigorous uterine contraction 3) Achievement of haemostasis Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  45. 45. NURSING DIAGNOSES IN THE THIRD47 STAGE OF LABOUR  Acute pain related to tissue trauma / psychological response following delivery as evidenced by verbalization / changes in muscle tone / restlessness  Risk for deficient fluid volume / Bleeding related to lack or restriction of oral intake, vomiting, diaphoresis, increased insensible water loss, uterine atony, lacerations of birth canal, retained placental fragments  Risk for maternal injury related to positioning during delivery and transfers / difficulty with placental separation / abnormal blood profile  Risk for impaired attachment related to physical barriers, separation, anxiety associated with the parent role Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  46. 46. NURSING MANAGEMENT48  Assess the maternal vital signs  Assess for excessive bleeding  Provide material for episiotomy repair  Take to recovery room and provide comfortable position  Prevention and measures for heamorrhage Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  47. 47. IV STAGE / RECOVERY STAGE49 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  48. 48. DEFINITION50 1 to 4 hours after the expulsion of placenta . Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  49. 49. NURSING DIAGNOSES IN THE FOURTH51 STAGE OF LABOUR Acute pain related effects of hormones & medications / mechanical trauma/ tissue edema/physical & psychological exhaustion/ anxiety as evidenced by reports of cramping/ muscle tremors/ guarding or distraction behavior/ facial mask Fatigue related to increased physical exertion, sleep deprivation, stress, environmental stimuli, hormonal changes evidenced by verbalization of overwhelming lack of energy, compromised concentration, listlessness Risk for bleeding related to myometrial fatigue / failure of hemostatic mechanism Risk for impaired attachment related to maternal fatigue/physical barrier/separation / lack of privacy/ anxiety associated with the parent role Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  50. 50. NURSING MANAGEMENT OF IV52 STAGE OF LABOR  Assess  Fundal location and consistency  Lochia amount , color , consistency , odour  Vital signs  Perineal or episiotomy care  Status of hydration  Bladder observation and distension  Fatigue and exhaustion Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  51. 51. MATERNAL SYSTEMIC RESPONSE TO LABOUR53 Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  52. 52. I CARDIO VASCULAR SYSTEM54  Increased BP in first and second stage of labor with a return to pre labor level during the third stage of labor  Other factors which increases BP are anxiety apprehension and pain  Increased Heart rate during second stage  Clinical manifestation of hypotension and increased pulse rate results from Supine vena caval syndrome Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  53. 53. II RESPIRATORY SYSTEM55  Oxygen consumption during labor is equal to that of moderate to strenuous exercise  Increased in ventilation until respiratory center is not depressed by medication  May quickly develop hypoxia or acidosis  Hyperventilation cause decreased Carbon- dioxide in blood 8/25/2012 Mata Sahib Kaur College of Nursing, Mohali, Punjab
  54. 54. III RENAL SYSTEM56  Muscle breakdown during labor results proteinuria. If it is more pre eclampsia results  Distended bladder may cause prolonged labor and urinary stasis which results risk of infection  Supine position may compress the ureters by distended uterine results decreased urinary flow Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  55. 55. V GASTRO INTESTINAL TRACT57 SYSTEM Decreased gastro intestinal peristaltic movement results from decreased absorption and decreased solid intake , because it can take 12 hrs to digest a meal Risk of aspiration of vomitus because of eating GI absorption of liquid is not changed Ice chips frequently can be given Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012
  56. 56. IV FLUID AND ELECTROLYTE58  Muscle activity increases BMR, body temperature, Sweating and fluid evaporation from the skin  Increased Perspiration  Increased respiratory rate  Hyper ventilation results from Labor alter the electrolyte balance  Adequate hydration and IV Fluid administration is necessary Mata Sahib Kaur College of Nursing, Mohali, Punjab 8/25/2012

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